In the Time of Cholera

How the U.N. created an epidemic -- then covered it up.

The horror was in the stomach, an empty, draining pain. All the way up the highway, Rosemond Lorimé had felt it running out of him. It was like the river running out of him, getting worse with every turn around the mountains.

Rosemond lived in a thatch-and-mud house in Meille, a small village on Haiti’s central plateau, built along a little river of the same name. There wasn’t much to do there, among the bean plants and banana trees, for a man of 21. You could swim or take a bath in the river. You could help the older folks raise pigs and turkeys, or plant cassava. Rosemond and his cousin would sell rum and kleren moonshine to the soldiers at the U.N. base, and introduce them to the neighborhood girls in exchange for a few dollars. But that was about it. Even the earthquake had been boring in Meille. The ground had just groaned and rumbled and stopped.

The sickness came nine months after. Rosemond’s father fell ill first. A low, hard pain formed in his gut and radiated all over his body. Then the diarrhea began, then vomiting, torrential like a fall storm. Soon everyone in the house was sick: Rosemond, his four brothers and sisters, his mother. The illness then moved into the neighboring houses. The family gathered up its money and sent Rosemond’s father to the hospital in the nearby town of Mirebalais. But it soon became clear that Rosemond’s sickness was the worst. Pain gripped his gut, and heat rose in his head and cut his intestines as if he’d eaten a stick of thorns. His stomach became a rejecting vessel. The water he drank would come back up or go straight out. Rice did the same. Even the garlic tea and cotton leaf that the women in the village gave him to settle his stomach ended up vomited or run out onto the ground. The diarrhea kept flowing; Rosemond became thirstier and thirstier. Neighbors whispered that it must be a spell.

The family looked for money to send Rosemond to the hospital too, but it took days to find enough. The day after his father returned home, weary but alive, Rosemond’s brothers put the slumping young man on the back of a motorcycle taxi to go to Mirebalais.

Under an arid sky, arms carried Rosemond into the little hospital with green-painted walls. A voice cried out in the room. Struggling for air, Rosemond closed his drying eyes and never opened them again. It was Sunday, Oct. 17, 2010.

***

I was grinding up Route Delmas toward the AP bureau in Pétionville with my fixer, Evens Sanon, when a news report came over on the radio:

"…the hospital in Saint-Marc. The Ministry of Public Health and Population reports that 41 people have died. Many are children. The patients arrive at the hospital with symptoms of vomiting, fever, and strong diarrhea. The Ministry of Public Health and Population urges all citizens in the Department of the Artibonite to watch for symptoms and report them…"

I suddenly felt sick too. Though experts at the World Health Organization, medical NGOs, and the U.S. Centers for Disease Control and Prevention (CDC) had been emphasizing that a major epidemic would be unlikely after the quake, they pushed out vaccinations to be sure. I’d dutifully chased down every lead, increasingly joining the experts in their skepticism. But something about this — the number of people, the specificity of the symptoms, and the pinpointing of a locale — was different. This sounded real. We pulled out our phones, Evens dialing the health ministry to try to confirm the report.

I did what I always did when major news broke in a part of Haiti I couldn’t reach immediately: I called the United Nations.

Yes, a spokeswoman said: There is a situation in Saint-Marc. An international team was making the 60-mile trip north from Port-au-Prince to Saint-Marc to investigate. And yes, there were dead: 19 confirmed. It was Wednesday, Oct. 20; three days, unbeknownst to us, after Rosemond Lorimé died.

Saint-Marc lies an hour up the coast from Port-au-Prince, just below the Artibonite River delta. The main hospital was overwhelmed with patients; more than 1,000 had flocked there from across the river valley. The sick and dying lay on soiled blankets in the parking lot, nurses darting around to put IVs in their arms. Police barricaded the hospital gate, letting only urgent cases through; relatives watched helplessly as their loved ones went in. The policemen covered their noses and mouths with surgical masks and bandannas, in case this mysterious disease was spreading through the air.

Cases of severe diarrhea, often terminal, began quickly showing up hospitals across the Artibonite Valley and into the neighboring Central Plateau. Health investigators took eight stool specimens to the national laboratory in Port-au-Prince. All tested positive for cholera. Health officials’ phones lit up all over the capital, then at the CDC in Atlanta, at the Haiti desk at the State Department in Washington, and at the U.N.’s WHO headquarters in Geneva. They all knew: Cholera was a remorseless killer, and it could move fast.

By weekend’s end, 200 people were dead.

The cameras were back on Haiti. Brian Williams set the tone on NBC: "It’s what all of us worried about when we arrived in Haiti just hours after the quake … beyond the death toll, the inevitable spread of disease. Now it’s happening in Haiti, an outbreak of cholera in that nation struggling every day, still, just to survive."

But the narrative didn’t make sense. If cholera was the inevitable result of the earthquake, centered 15 miles southwest of the capital, why had the first concentration of cases appeared in the countryside, some 45 miles to the north? And why had it taken nine months to appear?

***

After natural disasters, survivors, responders, and journalists tend to assume that a disease epidemic may be imminent, due to the collapse of sanitation or simply the feeling that misery comes in bunches.

In Haiti after the quake, there had been thousands of corpses in the streets, the stench of their decomposition filling the air. Though their fear was misplaced, already frightened survivors imagined the smell itself might prove a vector for disease. That was how a preacher convinced the people of a Port-au-Prince slum to give up their children to a group of U.S. Baptist missionaries (who would soon after be arrested for human trafficking at the border).

If the locals were scared of the dead, the foreigners were terrified of the living. The squalid camps home to millions of homeless Haitians were portrayed by the media as breeding grounds for infection, and the distribution of clean water and vaccinations there became central goals of the relief effort. Hollywood star Sean Penn — the most famous, if unexpected, of the post-quake campaigners — set off a panic by warning of a diphtheria epidemic after finding a single fatal case in May. After his warning proved overblown, the scares all but ended. Many aid groups began highlighting the lack of an epidemic as a rare victory for the humanitarian effort. Others called it a miracle.

In fact, researchers have consistently found that the risk of post-disaster epidemics is wildly overstated. A team of French researchers has found that out of more than 600 disasters between 1985 and 2004, only three resulted in significant outbreaks of disease. The risk is only slightly larger when large numbers of people are displaced. This was the reason the WHO and other health organizations had attempted at every turn to tone down the alarm raised by Sean Penn and the media.

Moreover, if a disease were going to spread, it would almost certainly have been already present before the earthquake. Because it spreads through contamination of food or water by human waste — emblems of bad sanitation — cholera is often associated with poverty. But poverty doesn’t cause cholera. You can have the world’s poorest people, the worst sanitation, hurricanes, earthquakes, frogs falling from the sky. Without the presence of Vibrio cholerae, the bacteria that causes the disease, you will not have cholera.

And there hadn’t been cholera in Haiti for at least 100 years.

***

From the outbreak’s first days, rumors coursed through Haiti that a U.N. base was the source. Some said they heard the sickness had begun when a U.N. soldier emptied a latrine into a water source. Others swore a white U.N. helicopter was seen dumping black powder into the Artibonite River — shades of Haitian folk sorcery, where a kou d poud, or powder attack, can cause death or zombification.

Then, on Oct. 25, a friend in Port-au-Prince sent me a link to a post on an epidemiology blog. It was titled: "Nepal: Cholera Outbreak in Kathmandu." The post linked to an article from the previous month in the Himalayan Times. Although Nepal is a cholera-endemic country — the disease is always present — there had been recent flare-ups. Doctors at a Katmandu hospital had warned that an outbreak was under way.

The U.N. soldiers stationed along the Artibonite River were from Nepal.

The next day, a U.N. press release arrived in my inbox. It was composed in the ultraformal diplomatic French of all U.N. memos in Haiti, but I could imagine it read in the bouncy Dominican-Italian lilt of its sender, Vincenzo Pugliese. The MINUSTAH press office was in flux — the last spokesman off to Darfur and the new spokeswoman not yet arrived — leaving Pugliese, the deputy, in charge. A teddy bear-shaped man with a receding hairline of brown, closely clipped hair, he talked with high animation and amiability that seldom concealed his disdain for the press.

The note made a series of claims: that the Nepalese base had "seven septic tanks" built to "construction standards of the [U.S.] Environmental Protection Agency," emptied "every week by four trucks from a private contractor." They were "250 meters from the river … representing more than 20 times the distance required at the international level." The management of the waste was "consistent with established international standards."

It was a lousy attempt at damage control — acknowledging the rumors and backing them up with a list of claims anyone could prove or disprove simply by heading to the base.

***

The village of Meille is a collection of concrete houses and thatch shacks thinly spread alongside National Road No. 3. The homes stretch out over the rolling knobs of earth along the road, peeking out through the trees. The U.N., meanwhile, built its base there to be seen. In a clearing, wedged between the highway and the Meille River, the soldiers had installed a high white gate and a series of even higher watchtowers surrounded by walls topped with concertina wire. The gate read:

UN

NEPALESE BATTALION

MINUSTAH HAITI

ANNAPURNA CAMP

Young men from the village were standing in front of the gate wearing backpacks and ball caps. Evens greeted them, approaching with open arms. "We heard someone dumped kaka in the river. Know anything about that?"

Heads nodded.

"Can you show us where?"

At once they turned and walked toward the base. We followed. Nepalese soldiers in green-and-brown camouflage and sky-blue helmets watched us from a guard tower. Just before the gate, the young men turned right and walked toward the back of the base, where only a steep, narrow slope of mud and rock separated the compound from the river. As we neared, they covered their noses and mouths. A second later, I realized why. The stench of rotting human filth was debilitating. We held our breath and crossed a concrete embankment along the ridge. Standing at the end was a U.N. solider with a blond ponytail sticking out of her blue cap, a Guatemalan flag on her epaulet. At her feet was a thick-sided black plastic case topped with security clasps.

"This isn’t good, is it?" I asked her in Spanish.

"No," she replied. She opened her mouth to say more, and then looked away.

Down the ridge, exposed, lay a broken PVC pipe. Running from near what looked like a building of latrines inside the perimeter, it leaked a black liquid toward the river. It stunk from several feet away. Farther down the ridge, Guatemalan military police took a sample of the waste, put it in a jar, and sealed it with a sky-blue lid. Then they brushed past us and left.

The Nepalese soldiers were staring through the base’s chain-link fence. One leaned over and took a concrete lid off an underground tank, releasing an overwhelmingly pungent blast of odor.

"WHOA! KAKA!" one of the villagers shouted. They started laughing.

Another villager tapped Evens on the shoulder. He was slightly older than the others, in a polo shirt, blue shorts, and galoshes speckled with what I hoped was mud.

"You and the blan should come with me across the road," he said.

The farmer led us past the concrete house he shared with his wife and five children; his wife held the youngest in her hands on the porch. Up a small hill, past a bony mule and some pigs, the smell returned. Ahead were two shining pools of feces, filling pits dug directly into the ground. "This is where MINUSTAH leaves their kaka," the farmer said.

A truck would come every few weeks from a Haitian company called SANCO, the farmer said — the contractor Pugliese had referred to. The truck would go into the base, suck out the septics, then drive across the street and dump the waste into the pools by his house. When it rained, the pools overflowed. Sometimes they ran down the hill into the river. Sometimes they flowed the other way, toward his house, and the smell would get so bad the family couldn’t sleep.

Then he led us down the hill to what looked like another pit full of human waste. This one had pigs and ducks swimming in it. A few weeks before, a new SANCO driver had shown up and dumped the excrement from the base in the wrong spot. Some of it had run down here. The farmer said he wasn’t sure exactly when — the days tend to run together in the countryside.

It did not take long for a key piece of his story to check out: Soon after, a green tanker truck marked SANCO Enterprises S.A. appeared at the base. The company vice president from Port-au-Prince followed in a white luxury pickup. I watched the truck hose up the contents of the U.N.’s underground tanks, drive across the street and up the hill, and stop at the pits. A worker jumped out of the truck, opened a valve in the rear, and took a big step back as a stream of black liquid surged into the open pit. Then, using an orange canister outfitted with a spray nozzle, he doused the surface of the new pool with bleach.

SANCO is one of the main waste disposal contractors in Port-au-Prince — the U.S. Department of Defense also contracted the company to handle some of its post-quake detritus. I learned later that SANCO had acquired the contract at the Nepalese base several months before by underbidding the preceding contractor. The truck driver told us that MINUSTAH had not called him to come in a month.

Could the septic tanks at the base have overflowed because they weren’t emptied on schedule? I tried to talk to the SANCO executive in the pickup, but she wouldn’t get out, rolling down the window only long enough to say: "It’s a very difficult client."

I asked the farmer if people had gotten sick drinking from the river. Some had, he said, days before. Many in Meille had stopped using the river’s water altogether. "You can’t even wash in it," he explained. Millions downstream hadn’t known that.

***

"Excuse me," I said, knocking on the base’s gate. "I’m a reporter with the Associated Press. We’d like to speak with the base commander."

Through gaps in the metal I could see Nepalese soldiers. Evens got back in the car and started honking. Finally a speakeasy-style flap opened and a soldier asked for my credentials.

An eternity passed. One of the village men started singing a song: "Ko-ko-kolera. Ko-le-ra MIN-U-STAH." His friends laughed. Finally a door opened, and a soldier beckoned us through. The base commander, slightly older, with stringy black hair and a camouflage uniform, was standing under a gazebo. He handed back my badges and motioned for us to sit down. He did not look pleased.

I asked him when his unit had arrived at the base.

He paused. "We came in shifts — three shifts. The first Oct. 9. Then Oct. 12. Then Oct. 16."

The unit had been in country for less than a month, which meant that its members had been in Nepal during the cholera outbreak. And the base would have been in the midst of rotation — with more personnel on hand than usual — right before the Haiti epidemic began.

"Could you show us around the base?"

"It is not possible today. You must go." He pointed to the digital recorder I was holding next to my notebook. "Put that away."

"It’s not on," I said. It wasn’t. I turned it on.

The commander had every reason to be nervous. U.N. peacekeeping is a cornerstone of the Nepalese defense budget. The U.N. pays countries more than $1,000 per peacekeeper per month, eight times the base pay for a private in Nepal. The soldiers are paid so well that Nepal obliges them to pay nearly a quarter of their U.N. salaries into a general welfare fund for the country’s soldiers and their families.

Evens and I took turns making our case. Each time the commander grew more insistent that we leave. I told him we had photos and video of the dump pits and leaking pipes, and that an Al Jazeera English crew that showed up after we did was filming too. Evens chimed in with the hard sell: "You’ll look very bad today. Today you’ll look very bad. Tell us the truth. We’ll put out the truth."

The commander shook his head. "What can I do?" he muttered to no one.

"Is anyone at the base sick?" I asked.

"No. You must go."

"Has anyone here been sick? Are there cases of cholera at the base?"

The commander rose to his feet. "I do not know cholera."

"You know cholera. There is cholera in Nepal, right? In Katmandu?"

Now, I will never be able to prove this. But if you ask me, right then, there were tears in his eyes.

By the night of our visit to Meille on Oct. 27, at least 303 people had died and 4,722 had been hospitalized. For the second time in a year, Haitian bodies were being piled into mass graves, nine months after the earthquake had claimed a government-estimated 316,000 lives. The most important river in the nation had become an artery of disease, and, as people fled the valley, the infection spread with them to every corner of the country.

As the disease spread, NGOs leapt into action, calling for donations and setting up mobile treatment centers. But the people in the communities did not trust them. Because the clinics would arrive just before families grew ill, many thought the clinics themselves were spreading the disease. Furious men pummeled aid stations with rocks and Molotov cocktails, burning tires and slashing the clinic tents. U.N. soldiers were sent to disperse the crowds.

The day after our story ran, CNN.com posted a follow-up, quoting Pugliese, that claimed all the Nepalese soldiers had tested negative for cholera before taking up their posts.

It took me a day to reach Pugliese. "When were the tests done?" I asked. "How many soldiers were tested? How were the results verified?"

Well, he said — CNN hadn’t gotten it quite right. It wasn’t that the soldiers tested negative. It’s that none of them tested positive. Because they had never been tested.

This turned out to not be unusual. The Medical Support Manual for United Nations Peacekeeping Operations lists neither diarrhea nor cholera as conditions precluding service. Worse, a standard medical examination has to take place only within three months of deployment, leaving plenty of time to be exposed to the disease.

On Oct. 29 — 12 days after the first hospitalized death from the disease, and two days after my first story from the base — protesters marched on the Nepalese installation. "The Nepalese brought this disease to the center of Mirebalais," a student shouted through a megaphone. The crowd chanted: "Like it or not, the U.N. must go." Among the marchers were cousins of Rosemond Lorimé.

The U.N. and its allies went on the defense. The peacekeeping mission had been stung by a series of scandals in Haiti in the six years since it arrived in the wake of a coup, and was resented by many Haitians as an occupying force. But for its faults, MINUSTAH was the vanguard of international aid and relief in Haiti, and a major investment by the world’s powers. From 2004 through 2012, the U.N. would spend more than $4.75 billion on mission, about a quarter paid by the United States. The Security Council often advertised the Haiti mission as a positive example of its works. If the U.N. were discovered to have caused the epidemic in Haiti, its credibility would be catastrophically compromised — Haitian lives destroyed by the very people sent to protect them.

"It’s not important right now," one WHO spokesperson said in response to a question I’d posed about the epidemic’s cause. It’s "not a priority," said another. But if figuring out where an infection comes from isn’t critical to containing an epidemic, what is?

***

Immediately after the protest, the U.N. invited my AP team to take a guided tour of the base. It was Oct. 31, half a month into the epidemic, and the mission wanted the rumors, and our previous reporting, squashed.

Pugliese greeted us at the gate alongside the Nepalese contingent’s chief officer. Young soldiers fresh from the Himalayas milled in polyester workout shorts and T-shirts. There was no sign of Commander Dengue.

It was immediately apparent that the soldiers had literally covered up the most incriminating evidence, starting with the smell. They admitted to having undertaken repairs, including replacing the broken PVC pipe from the back of the base and scrubbing a drainage canal that emptied into the river. Yet the repairs had been superficial at best. A series of aboveground pipes that originated at the latrines still ran over the drainage canal, their cracks showing. One pipe was held together with what looked like electrical tape. In the river below, where the canal let out, a soupy brown mixture bubbled along the bank. Flies swarmed over it.

"What is that?" I asked Pugliese.

"That … that could be anything."

A villager was swimming a few yards away.

"It — it does not mean it is from the base," he said. "The people here, they swim in the river. They bathe in it." He pointed to the swimming man. "They — you know how they are!"

That was the end of the tour. The U.N. team refused to go across the street with us to see the dump pits.

The next day, less than two weeks after the outbreak was first confirmed, the CDC put out the results of an analysis it had undertaken: The cholera in Haiti matched strains circulating in South Asia, including Nepal. It refused to investigate further.

The death toll passed 400.

***

Authorities defended their refusal to investigate the origin of the outbreak on grounds that pursuing the source would detract from fighting the epidemic. So on Nov. 3, I called one of the most prominent public health experts in Haiti, if not the world. Paul Farmer’s medical NGO, Partners in Health, was taking a leading role in tackling cholera. I asked if there was a public health rationale not to investigate. "That sounds like politics to me, not science," Farmer replied.

Health officials look into the source of cholera outbreaks all the time. In fact, the modern practice of epidemiology was built on the disease in 1854, when a physician named John Snow set out to find the source of one of London’s worst cholera outbreaks. Such investigation is still the practice. In a 2004 guide, the WHO recommended investigating each outbreak’s origin "so that appropriate control measures can be taken."

Those seeking to protect the U.N. — the WHO and CDC, sympathetic journalists, aid workers and diplomats who depended on the U.N. for protection on the ground — kept coming back to a three-word phrase: "the blame game." The journal Science would later note that cholera experts’ "passion for traditional shoe-leather epidemiology [had] been tempered by diplomatic and strategic concerns."

Most journalists, particularly those not based in Haiti, seemed to feel the same way. They stayed away from the story until there was too much evidence to ignore, and then did their best to beat it back. When the New York Times published a story about the U.N. defending its anti-investigation stance, three weeks after our visit to the Nepalese base, health reporter Donald G. McNeil, Jr. wrote a Week in Review piece titled "Cholera’s Second Fever: An Urge to Blame." He gave past examples of cholera "blame games," including 19th-century New Yorkers accusing Canadians and the Irish. He warned of danger: "Scapegoating provokes violence."

The U.N. was not a threatened minority, but the most powerful military force in the nation, if not the region. In fact, as the dramatic events of November 2010 would soon show, it was stonewalling that would provoke the Haitian crowds. By refusing to take the concerns seriously, investigators would cede inquiry to the very agitators and xenophobes they feared.

***

In two years, more than 7,800 Haitians have died of cholera. One in five people in a nation of roughly 10 million has fallen seriously ill with the disease, while the unusually virulent strain has spread across the Caribbean, into South America, and the United States.

The United Nations has made grandiose, if seemingly empty, promises to fight and eradicate the disease, but refuses to consider its own accountability in starting the epidemic. Aid workers and donor governments have lost a critical opportunity — to demonstrate that they took Haitian lives and welfare as seriously as their own.